The nurse will be using the Braden Scale with each admit to the longterm care center. Which of these will be utilized in a Braden Scale assessment? (Select all that apply.)

Choice A reason: Deeply palpating the area for rebound tenderness is not the nurse's next action, because it is inappropriate and dangerous. Deeply palpating the area for rebound tenderness is a test that involves applying and releasing pressure on the abdomen, which can elicit pain or discomfort in the presence of peritonitis or appendicitis. Deeply palpating the area for rebound tenderness is not relevant or useful for the client's complaint of pain and burning in the right calf area, which may indicate a deep vein thrombosis (DVT), which is a blood clot in the deep veins of the leg. Deeply palpating the area for rebound tenderness can also worsen the pain, damage the tissues, or dislodge the clot, which can cause pulmonary embolism, which is a lifethreatening condition.

Choice B reason: Percussing over the area for a change in tone is not the nurse's next action, because it is inappropriate and useless. Percussing over the area for a change in tone is a test that involves tapping on the chest or abdomen, which can produce different sounds depending on the density of the underlying organs or tissues. Percussing over the area for a change in tone is not relevant or useful for the client's complaint of pain and burning in the right calf area, which may indicate a deep vein thrombosis (DVT), which is a blood clot in the deep veins of the leg. Percussing over the area for a change in tone can also worsen the pain, damage the tissues, or dislodge the clot, which can cause pulmonary embolism, which is a lifethreatening condition.

Choice C reason: Comparing the circumference to the left calf is the nurse's next action, because it is appropriate and useful. Comparing the circumference to the left calf is a test that involves measuring the size of the leg, which can reveal any swelling or edema in the affected area. Comparing the circumference to the left calf is relevant and useful for the client's complaint of pain and burning in the right calf area, which may indicate a deep vein thrombosis (DVT), which is a blood clot in the deep veins of the leg. Comparing the circumference to the left calf can also help diagnose, monitor, or treat the condition, as a difference of more than 2 cm between the legs can suggest a DVT.

Choice D reason: Medicating the client for pain and reassessing in 60 minutes is not the nurse's next action, because it is inappropriate and delayed. Medicating the client for pain and reassessing in 60 minutes is an intervention that involves giving the client a painkiller and checking the response after an hour. Medicating the client for pain and reassessing in 60 minutes is not relevant or useful for the client's complaint of pain and burning in the right calf area, which may indicate a deep vein thrombosis (DVT), which is a blood clot in the deep veins of the leg. Medicating the client for pain and reassessing in 60 minutes can also mask the symptoms, delay the diagnosis, or miss the opportunity to prevent the complications, such as pulmonary embolism, which is a lifethreatening condition.

Choice A reason: Truck driver is not an occupation that increases the risk for carpal tunnel syndrome, because it does not involve repetitive or forceful flexion or extension of the wrist. Carpal tunnel syndrome is a condition that occurs when the median nerve, which runs through the carpal tunnel in the wrist, is compressed or irritated by inflammation, swelling, or pressure. Truck drivers may experience other musculoskeletal problems, such as back pain, neck pain, or shoulder pain, due to prolonged sitting, vibration, or poor posture.

Choice B reason: Nursing assistant is an occupation that increases the risk for carpal tunnel syndrome, but it is not the best answer, because it involves other factors besides repetitive motion that can contribute to the condition. Nursing assistants may perform repetitive tasks, such as lifting, transferring, or bathing patients, that can strain the wrist and the median nerve. However, they may also experience other risk factors, such as trauma, infection, arthritis, or pregnancy, that can cause carpal tunnel syndrome.

Choice C reason: Elementary school teacher is not an occupation that increases the risk for carpal tunnel syndrome, because it does not involve repetitive or forceful flexion or extension of the wrist. Elementary school teachers may perform some tasks, such as writing, typing, or grading papers, that can involve wrist movement, but they are not likely to be frequent or intense enough to cause carpal tunnel syndrome. Elementary school teachers may experience other stressrelated problems, such as headaches, fatigue, or burnout, due to the demands of their work.

Choice D reason: Assembly line worker is the best answer, because it is an occupation that increases the risk for carpal tunnel syndrome, due to the nature and duration of the work. Assembly line workers may perform repetitive, forceful, or awkward movements of the wrist, such as twisting, bending, or gripping, that can cause compression or irritation of the median nerve. Assembly line workers may also work for long hours, with little rest or variation, that can exacerbate the condition.